Keri R. Hainsworth

Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial.

BACKGROUND: Gabapentin has opioid-sparing effects in adult surgical patients, but no reported studies have involved children and adolescents. In a double-blind, randomized, controlled trial, we examined whether gabapentin decreases postoperative opioid consumption for pediatric spinal fusion patients with idiopathic scoliosis. METHODS: Patients, aged 9 to 18 years, received preoperative gabapentin (15 mg/kg, treatment) or placebo. Anesthesia was standardized. After surgery, all patients received standardized patient-controlled analgesia opioid and continued on either gabapentin (5 mg/kg) or placebo 3 times per day for 5 days. Opioid use was calculated in mg/kg/time intervals. Pain scores and opioid side effects were recorded. RESULTS: Data from 59 patients (30 placebo and 29 gabapentin) did not differ in demographics. Total morphine consumption (mg/kg/h ± SD) was significantly lower in the gabapentin group in the recovery room (0.044 ± 0.017 vs 0.064 ± 0.031, P = 0.003), postoperative day 1 (0.046 ± 0.016 vs 0.055 ± 0.017, P = 0.051), and postoperative day 2 (0.036 ± 0.016 vs 0.047 ± 0.019, P = 0.018). In addition, gabapentin significantly reduced first pain scores in the recovery room (2.5 ± 2.8 vs 6.0 ± 2.4, P < 0.001) and the morning after surgery (3.2 ± 2.6 vs 5.0 ± 2.2, P < 0.05), but otherwise pain scores were not significantly different. There were no differences in opioid-related side effects over the course of the study. CONCLUSION: Perioperative oral gabapentin reduced the amount of morphine used for postoperative pain after spinal fusion surgery, but not overall opioid-related side effects. Initial pain scores were lower in the treatment group. Perioperative use of gabapentin seems to be an effective adjunct to improve pain control in the early stages of recovery in children and adolescents undergoing spinal fusion.

School Functioning and Chronic Pain: A Review of Methods and Measures

OBJECTIVE School functioning is among the most important life domains impacted by chronic pain. This review provides a summary of the measures currently used by researchers to assess school functioning in children with chronic pain. METHODS We conducted a systematic review of the literature on school absenteeism and school functioning in children and adolescents with pain. Searches were restricted to a time frame including January 1985 to December 2010. RESULTS Fifty-three articles are reviewed: all include some form of assessment of school absenteeism or school functioning as part of the study outcome measures. Of the 53 articles, 26 assessed school absenteeism and 27 assessed an aspect of school functioning; 14 of these 27 articles assessed both. CONCLUSIONS Understanding the comprehensive impact of pain on school functioning will require improvements in our current assessment methods.

Spectral restoration of speech: Intelligibility is increased by inserting noise in spectral gaps

In order to function effectively as a means of communication, speech must be intelligible under the noisy conditions encountered in everyday life. Two types of perceptual synthesis have been reported that can reduce or cancel the effects of masking by extraneous sounds: Phonemic restoration can enhance intelligibility when segments are replaced or masked by noise, and contralateral induction can prevent mislateralization by effectively restoring speech masked at one ear when it is heard in the other. The present study reports a third type of perceptual synthesis induced by noise: enhancement of intelligibility produced by adding noise to spectral gaps. In most of the experiments, the speech stimuli consisted of two widely separated narrow bands of speech (center frequencies of 370 and 6000 Hz, each band having high-pass and low-pass slopes of 115 dB/octave meeting at the center frequency). These very narrow bands effectively reduced the available information to frequency-limited patterns of amplitude fluctuation lacking information concerning formant structure and frequency transitions. When stochastic noise was introduced into the gap separating the two speech bands, intelligibility increased for “everyday” sentences, for sentences that varied in the transitional probability of keywords, and for monosyllabic word lists. Effects produced by systematically varying noise amplitude and noise bandwidth are reported, and the implications of some of the novel effects observed are discussed.

School Absenteeism in Pediatric Chronic Pain: Identifying Lessons Learned From the General School Absenteeism Literature

Although the high rates of school absenteeism among children and adolescents with chronic pain have been well-documented, school absenteeism among these youths remains a poorly understood phenomenon. Literature focusing on school avoidance or refusal in the general (non-pain) population holds potential for contributing to a better understanding of problematic school absenteeism in the pediatric chronic pain population. This article presents a focused review of what is known about school absenteeism in pediatric chronic pain and how the literature on problematic absenteeism in the general population can inform an understanding of this phenomenon.

Distinct Influences of Anxiety and Pain Catastrophizing on Functional Outcomes in Children and Adolescents With Chronic Pain

OBJECTIVES Examine whether anxiety and pain catastrophizing are distinct constructs in relation to functional outcomes in pediatric chronic pain, and whether they differentially predict functional outcomes based on age. METHODS In all, 725 youth (191 children, 534 adolescents) with chronic pain completed measures of pain characteristics, anxiety, pain catastrophizing, functional disability, and health-related quality of life (HRQOL). Structural equation modeling was used to examine interrelationships. RESULTS Anxiety and pain catastrophizing were distinct. For both children and adolescents, pain catastrophizing predicted pain, functional disability, and HRQOL, and was a stronger predictor of pain intensity. For children, anxiety predicted HRQOL, and pain catastrophizing was a stronger predictor of functional disability. For adolescents, anxiety predicted functional disability and HRQOL, and anxiety was a stronger predictor of HRQOL. CONCLUSIONS There were age-related differences regarding whether anxiety or pain catastrophizing more strongly predicted specific functional outcomes. Assessment and intervention efforts should emphasize both anxiety and pain catastrophizing.

Co-occurring chronic pain and obesity in children and adolescents: the impact on health-related quality of life.

ObjectivesDetermine the impact of cooccurring chronic pain and obesity on health-related quality of life (HRQOL) in children and adolescents. MethodsRetrospective chart review of 319 children and adolescents (8 to 18 y) seen at a multispecialty chronic pain clinic. HRQOL was measured with the Pediatric Quality of Life Inventory (v.4.0). Total, physical and psychosocial summary scores, and subscale scores for emotional, social, and school functioning were compared for youth across weight groups (healthy weight, overweight, obese). Odds ratios (ORs) were calculated to assess the likelihood of impaired HRQOL with a combined impact of chronic pain and obesity compared with chronic pain alone. Using previously published data; we also assessed the likelihood of impaired HRQOL with a combined impact of chronic pain and obesity compared with obesity alone. ResultsAcross all domains of functioning, children and adolescents in the obese group reported lower HRQOL than the overweight and healthy weight groups. Emotional functioning was the exception; the obese group reported lower scores than the overweight group, but not the healthy weight group. The likelihood of impaired HRQOL was higher [OR, 2.2; 95% confidence interval (CI): 1.1-4.4] for children and adolescents with chronic pain and obesity than with chronic pain alone and higher than children and adolescents with obesity alone (OR, 3.7; 95% CI: 1.8-7.8). DiscussionCooccurring chronic pain and obesity exacerbates the impact of chronic pain alone on the HRQOL of children and adolescents. Routinely screening pediatric patients with chronic pain for elevated body mass index is recommended.

Initial surgical and pain management outcomes after Nuss procedure

PURPOSE The purpose of this article was to report surgical and pain management outcomes of the initial Nuss procedure experience at the Childrens Hospital of Wisconsin (Milwaukee) and to place this experience in the context of the published literature. METHODS The initial 118 consecutive Nuss procedures in 117 patients were retrospectively reviewed with approval of the Childrens Hospital of Wisconsin human rights review board. Patient, surgical, complication, and pain descriptors were collected for each case. Statistical methods for comparison of pain strategies included the Kolmogorov-Smirnov test for normality, 1-way repeated measures analysis of variance, and paired t tests. RESULTS Patient, surgical, and complication descriptors were comparable to other large series. Complication rates were 7% early and 25% late. Epidural success rate was 96.4%. There was 1 episode of recurrence 2 years postbar removal (n = 114). CONCLUSIONS The institution of the Nuss procedure provides a highly desired result with significant complication rates. The ideal approach would deliver this result with lower risk. A pain service-driven epidural administration of morphine or hydromorphone with local anesthetic provides excellent analgesia for patients after Nuss procedure. The success of epidural analgesia is independent of catheter site and adjunctive medications. Ketorolac was an effective breakthrough medication.

Neurostimulation for abdominal pain-related functional gastrointestinal disorders in adolescents: a randomised, double-blind, sham-controlled trial

BACKGROUND Development of safe and effective therapies for paediatric abdominal pain-related functional gastrointestinal disorders is needed. A non-invasive, US Food and Drug Administration-cleared device (Neuro-Stim, Innovative Health Solutions, IN, USA) delivers percutaneous electrical nerve field stimulation (PENFS) in the external ear to modulate central pain pathways. In this study, we evaluated the efficacy of PENFS in adolescents with abdominal pain-related functional gastrointestinal disorders. METHODS In this randomised, sham-controlled trial, we enrolled adolescents (aged 11-18 years) who met Rome III criteria for abdominal pain-related functional gastrointestinal disorders from a single US outpatient gastroenterology clinic. Patients were randomly assigned (1:1) with a computer-generated randomisation scheme to active treatment or sham (no electrical charge) for 4 weeks. Patients were stratified by sex and presence or absence of nausea. Allocation was concealed from participants, caregivers, and the research team. The primary efficacy endpoint was change in abdominal pain scores. We measured improvement in worst abdominal pain and composite pain score using the Pain Frequency-Severity-Duration (PFSD) scale. Participants with less than 1 week of data and those with organic disease identified after enrolment were excluded from the modified intention-to-treat population. This trial has been completed and is registered with ClinicalTrials.gov, number NCT02367729. FINDINGS Between June 18, 2015, and Nov 17, 2016, 115 children with abdominal pain-related functional gastrointestinal disorders were enrolled and assigned to either PENFS (n=60) with an active device or sham (n=55). After exclusion of patients who discontinued treatment (n=1 in the PENFS group; n=7 in the sham group) and those who were excluded after randomisation because they had organic disease (n=2 in the PENFS group; n=1 in the sham group), 57 patients in the PENFS group and 47 patients in the sham group were included in the primary analysis. Patients in the PENFS group had greater reduction in worst pain compared with sham after 3 weeks of treatment (PENFS: median score 5·0 [IQR 4·0-7·0]; sham: 7·0 [5·0-9·0]; least square means estimate of change in worse pain 2·15 [95% CI 1·37-2·93], p<0·0001). Effects were sustained for an extended period (median follow-up 9·2 weeks [IQR 6·4-13·4]) in the PENFS group: median 8·0 (IQR 7·0-9·0) at baseline to 6·0 (5·0-8·0) at follow-up versus sham: 7·5 (6·0-9·0) at baseline to 7·0 (5·0-8·0) at follow-up (p<0·0001). Median PFSD composite scores also decreased significantly in the PENFS group (from 24·5 [IQR 16·8-33.3] to 8·4 [3·2-16·2]) compared with sham (from 22·8 [IQR 8·4-38·2] to 15·2 [4·4-36·8]) with a mean decrease of 11·48 (95% CI 6·63-16·32; p<0·0001) after 3 weeks. These effects were sustained at extended follow-up in the PENFS group: median 24·5 (IQR 16·8-33·3) at baseline to 12 (3·6-22·5) at follow-up, compared with sham: 22·8 (8·4-38·2) at baseline to 16·8 (4·8-33·6) at follow-up (p=0·018). Ten patients reported side-effects (three of whom discontinued the study): ear discomfort (n=6; three in the PENFS group, three in the sham group), adhesive allergy (n=3; one in the PENFS group, two in the sham group), and syncope due to needle phobia (n=1; in the sham group). There were no serious adverse events. INTERPRETATION Our results show that PENFS with Neuro-Stim has sustained efficacy for abdominal pain-related functional gastrointestinal disorders in adolescents. This safe and effective approach expands treatment options and should be considered as a non-pharmacological alternative for these disorders. FUNDING American Neurogastroenterology and Motility Society.

Predicting Multiple Facets of School Functioning in Pediatric Chronic Pain: Examining the Direct Impact of Anxiety.

Objectives:The relationships among chronic pain, anxiety, and school functioning are complex, and school functioning is often negatively impacted in youth with chronic pain. The objective of this study was to empirically test a model of associations between constructs predicting school functioning in youth with chronic pain to examine the direct effect of anxiety on school attendance and other indicators of school-related disability. Materials and Methods:Participants included 349 youth and their parents (311 mothers and 162 fathers) who attended a multidisciplinary pain clinic. Youth, mothers, fathers, and clinicians completed assessments of clinical outcomes important to family and clinician perceptions of school functioning; youth, mothers, and fathers completed an assessment of youth anxiety. Structural equation modeling was used to examine interrelations among predictors. Results:Measurement and structural models for predicting youth school functioning provided a very good fit of the data to the conceptual model. Anxiety was directly related to problems with school attendance and avoidance, concentration, and keeping up with schoolwork. Discussion:Anxiety was a robust predictor of school functioning across a range of domains. Evaluating anxiety symptoms in pediatric chronic pain will likely facilitate case conceptualization and treatment planning. This study supports a shift in focus from pain to anxiety as the driving force of school impairment in youth with chronic pain.

A pilot study of yoga for chronic headaches in youth: promise amidst challenges.

The primary aim of the current study was to provide preliminary data on the feasibility, acceptability, and safety of alignment-based yoga for youths with chronic headaches. A secondary aim was to provide preliminary estimates of yogas ability to improve headache pain, daily functioning, quality of life, and anxiety level in this population. The yoga intervention consisted of 8 weekly, 75-minute classes. Participant flow data revealed challenges to feasibility primarily due to recruitment and retention. Scores on most outcome measures changed in the predicted direction with medium effect sizes found for the functional outcomes. Pain measures did not change significantly. This pilot suggests that yoga for pediatric headaches may be acceptable, as indicated by positive parent and participant ratings of the yoga experience. These preliminary findings suggest that yoga trials for pediatric headaches include both challenges and promise. Recommendations for overcoming challenges include designs that optimize family convenience.